1(E): tLOC

Question 1

What are 5 neurological causes of black-out

Answer 1

• Epileptic seizure
• Raised ICP
• SAH
• Narcolepsy
• CVD

Question 2

What are 3 cause of neural mediated syncope

Answer 2

1. Carotid Sinus Syncope
2. Vaso-vagal
3. Situational syncope

Question 3

What are 2 cardiac causes of syncope

Answer 3

Arrhythmias

Obstruction - HOCM, Aortic stenosis

Question 4

What can cause orthostatic hypotension leading to syncope

Answer 4

Medication

Autonomic dysfunction - MS, PD, Diabetes

Addison’s

Question 5

What metabolic disorders can cause syncope

Answer 5

Hypoxia

Hypoglycaemia

Question 6

What psychiatric causes of syncope

Answer 6

Psychiatry non-epileptic attacks

Question 7

Explain triggers in

a. Epilepsy
b. Syncope

Answer 7

a. Rare: flashing lights, alcohol, sleep deprivation

b. Common (eg. Blood, Dehydration)

Question 8

Explain pro-drome in

a. Epilepsy
b. Syncope

Answer 8

a. May have an aura

b. Very common - lightheadedness, dizziness

Question 9

Describe onset of seizure

Answer 9

Very quick

Question 10

Describe onset of syncope

Answer 10

Gradual

Question 11

Describe duration of seizure

Answer 11

1-3 minutes

Question 12

Describe duration of syncope

Answer 12

30 seconds

Question 13

What are common features of seizures. but not syncope

Answer 13

Tongue biting
Incontinence
Post-Ictal confusion

Question 14

What colour are individuals during seizures

Answer 14

Blue - cyanosed

Question 15

What colour are individuals during syncope

Answer 15

Pale

Question 16

What is a vasovagal

Answer 16

Sudden bradycardia and peripheral vasodilation caused by external stimuli causes collapse

Question 17

What are key features of vasovagal attacks

Answer 17

Pre-syncopal symptoms. Last seconds

Question 18

Why may jerking occurring in vasovagal attacks

Answer 18

Hypoxia causing tonic-clonic jerks

Question 19

What is situational syncope

Answer 19

LOC evoked in specific situations

Question 20

What is difference between situational syncope and vasovagal

Answer 20

Similar to vasovagal but evoked by certain events

Question 21

What. are two types of situational syncope

Answer 21

• Micturition syncope

- Exertions syncope

Question 22

What are stoke adams attacks

Answer 22

Drop in CO leading to LOC, caused by arrythmia such as bradycardia due to heart block

Question 23

How does patient present in stoke adams attacks

Answer 23

Palpitations then suddenly drops to ground. During attack the pulse cannot be felt or is slow.

Question 24

Explain recovery in stokes adams

Answer 24

patient recovers in seconds, they flush, pulse speeds up and consciousness is regained

Question 25

What are drop attacks

Answer 25

Patient suddenly drops to ground without LOC

Question 26

What causes drop attacks

Answer 26

- Narcolepsy - Cataplexy - Leg weakness - Hydrocephalus

Question 27

What should all individuals with tLOC have ordered

Answer 27

ECG

Question 28

What other blood tests should be ordered in tLOC

Answer 28

``` Blood Glucose (hypoglycaemia) Hb (anaemia) ```

Question 29

If someone has a red-flag what should happen

Answer 29

Refer for urgent cardiovascular assessment in 24-hours

Question 30

What are red flags of tLOC

Answer 30

- Abnormality ECG - tLOC during exercise - FH sudden cardiac death under 45-years - New-onset breathlessness - New murmur - HF

Question 31

Explain referral in over 65-years

Answer 31

Refer anyone over 65 with tLOC without prodrome for urgent cardiovascular assessment in 24-hours

Question 32

If suspected structural heart disease, what investigation is performed

Answer 32

ECHO

Question 33

If suspecting arrhythmia. what investigation is performed

Answer 33

Holter ECG (Ambulatory ECG)

Question 34

If suspect carotid sinus syndrome - what investigation is performed

Answer 34

Carotid Sinus Massage

Question 35

If unidentified cause of tLOC and patient is under 65 what is offered

Answer 35

Holter Monitor (Ambulatory ECG)

Question 36

If unidentified cause of tLOC and patient is over 65 what is offered

Answer 36

Carotid Sinus Massage

Question 37

If patient has tLOC several times a week, how long is hotter monitoring offered

Answer 37

48h

Question 38

If no event seen on holter monitor, what is offered

Answer 38

External event recorder

Question 39

If individual has tLOC every 1-2 weeks what is offered

Answer 39

External event recorder

Question 40

if individual has tLOC less than every 2 weeks what is offered

Answer 40

Implantable recorder

Question 41

If no red flags, who may tLOC be referred to

Answer 41

Neurology

Question 42

If suspect vasovagal or situational syncope, what is done

Answer 42

Nothing

Question 43

If suspect epilepsy, what is done

Answer 43

Refer to epilepsy specialist in 2W

Question 44

If suspect orthostatic hypotension what is done

Answer 44

Lying-standing BP

Question 45

Explain lying standing BP

Answer 45

Drop in 20/10mmHg after 3-minutes is positive